Radial Artery Versus Right Internal Thoracic Artery Versus Saphenous Vein as the Second Conduit for Coronary Artery Bypass Surgery: A Network Meta‐Analysis of Clinical Outcomes

<jats:sec xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en"> There remains uncertainty regarding the second‐best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery ( <jats:styled-content style="fixed-case">RA</jats:styled-content> ), right internal thoracic artery ( <jats:styled-content style="fixed-case">RITA</jats:styled-content> ), and saphenous vein ( <jats:styled-content style="fixed-case">SV</jats:styled-content> ). No network meta‐analysis has compared these 3 strategies. </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> <jats:styled-content style="fixed-case">MEDLINE</jats:styled-content> and <jats:styled-content style="fixed-case">EMBASE</jats:styled-content> were searched for adjusted observational studies and randomized controlled trials comparing the <jats:styled-content style="fixed-case">RA</jats:styled-content> , <jats:styled-content style="fixed-case">SV</jats:styled-content> , and/or <jats:styled-content style="fixed-case">RITA</jats:styled-content> as the second conduit for coronary artery bypass grafting. The primary end point was all‐cause long‐term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection ( <jats:styled-content style="fixed-case">DSWI</jats:styled-content> ). Pairwise and network meta‐analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included ( <jats:styled-content style="fixed-case">RA</jats:styled-content> , 16 201, <jats:styled-content style="fixed-case">SV</jats:styled-content> , 112 018, <jats:styled-content style="fixed-case">RITA,</jats:styled-content> 21 683). At <jats:styled-content style="fixed-case">NMA</jats:styled-content> , the use of <jats:styled-content style="fixed-case">SV</jats:styled-content> was associated with higher long‐term mortality compared with the <jats:styled-content style="fixed-case">RA</jats:styled-content> (incidence rate ratio, 1.23; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> , 1.12–1.34) and <jats:styled-content style="fixed-case">RITA</jats:styled-content> (incidence rate ratio, 1.26; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> , 1.17–1.35). The risk of <jats:styled-content style="fixed-case">DSWI</jats:styled-content> for <jats:styled-content style="fixed-case">SV</jats:styled-content> was similar to <jats:styled-content style="fixed-case">RA</jats:styled-content> but lower than <jats:styled-content style="fixed-case">RITA</jats:styled-content> (odds ratio, 0.71; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> , 0.55–0.91). There were no differences for any outcome between <jats:styled-content style="fixed-case">RITA</jats:styled-content> and <jats:styled-content style="fixed-case">RA</jats:styled-content> , although <jats:styled-content style="fixed-case">DSWI</jats:styled-content> trended higher with <jats:styled-content style="fixed-case">RITA</jats:styled-content> (odds ratio, 1.39; 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> , 0.92–2.1). The risk of <jats:styled-content style="fixed-case">DSWI</jats:styled-content> in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used. </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en"> The use of the <jats:styled-content style="fixed-case">RA</jats:styled-content> or the <jats:styled-content style="fixed-case">RITA</jats:styled-content> is associated with a similar and statistically significant long‐term clinical benefit compared with the <jats:styled-content style="fixed-case">SV</jats:styled-content> . There are no differences in operative risk or complications between the 2 arterial conduits, but <jats:styled-content style="fixed-case">DSWI</jats:styled-content> remains a concern with bilateral <jats:styled-content style="fixed-case">ITA</jats:styled-content> when skeletonization is not used. </jats:p> </jats:sec>